Successful, “innovative” primary health care (PHC) models exist that have adapted to the specific circumstances of their rural and remote context.
A typology of discrete, integrated, comprehensive and outreach rural and remote services exists rather than a “one coat fits all” PHC health service model.
Successful models are characterised by macro-scale environmental enablers (supportive health policy, federal–state relations, and community readiness) and five essential service requirements (workforce organisation and supply; funding; governance, management and leadership; linkages; and infrastructure).
Service sustainability depends on ensuring that key systemic service requirements are met at the local level in ways that accord with, and are supported by, the broader macro-scale environmental enablers.
Based on these principles, these model types are amenable to generalisation and evaluation in other regions.
In Australia, over the past decade, considerable research and many government programs have focused on ways to increase medical workforce supply, recruitment and retention.1-5 The limited success achieved to date in redressing rural and remote medical workforce undersupply has stimulated a call for “a continuing and holistic overview of what is actually happening at the grassroots level in providing rural and remote communities with appropriate and safe health care”, rather than any more surveys on recruitment and retention.6
The problem of how to provide accessible, sustainable, appropriate health care services is most acute in small rural and remote communities, where the increased costs and difficulties of workforce recruitment and retention are compounded by the lack of economies of scale associated with servicing small populations dispersed over vast distances. Research on the need to ensure the provision of sustainable health services has been limited.7-10
For this reason, our systematic review identifying the key requirements underpinning sustainable health care services to meet the diverse health needs of small rural and remote communities in Australia is timely.11 Here we present the highlights of our review.
Geographically large countries like Australia and Canada face enormous problems in servicing the health needs of their populations.12,13 In Australia, various health care models have evolved to meet the needs of non-metropolitan inhabitants. Where populations are insufficient to meet the range and threshold requirements necessary to support local health care services, consumers have to travel long distances to larger regional centres or depend on visiting services at irregular intervals, with emergency care provided by the Royal Flying Doctor Service or air ambulance.14 Alternatively, consumers forgo care or present late — factors that arguably contribute to the poorer health status of rural and remote residents.15,16
While the role of general practice within PHC services is central, the dominant doctor-centred, fee-for-service model may not necessarily be the optimal service delivery model in rural and remote areas.17 Increasingly, the need to adopt a comprehensive PHC model involving multidisciplinary teams is recognised. Indeed, Starfield has argued that a PHC approach yields the best health outcomes, particularly in situations of limited resources.18,19
Since 1993, Australian governments have funded numerous “innovative” pilot models for small rural and remote communities, few of which have been comprehensively evaluated. Our systematic review of rural and remote PHC models in Australia provided a comprehensive evidence base to underpin effective rural and remote health service policies and programs.
Our methodology, outlined in detail elsewhere,11 identified 68 of some 5391 initial meta-database “hits” that met the search criteria — namely, English-language reports on Australian rural and remote PHC models based on primary or secondary evidence about structural and financial aspects of sustainable service provision.
Our review identified several rural and remote PHC models (Box 1). In recognition of the diversity of rural and remote regions, the actual health service configurations differ significantly. Communities with sufficient population size are able to support discrete health care services, while smaller, more dispersed populations depend on integrated or outreach arrangements.11
Each successful primary health service model, regardless of its specific design, is characterised by common inter-related and interdependent factors that underpin its sustainability (Box 2). These requirements comprise macro-scale environmental enablers and specific requirements operating at the service level.
At the macro level, the policy environment must be conducive to facilitating services that take account of the specific health needs and circumstances of rural and remote communities that are not adequately met through mainstream programs and models. Small rural communities often suffer because national and state policies do not fit every case. In a federated political system, governments at all levels need to agree on outcomes that guide the purpose and nature of the health service in order to avoid unnecessary duplication of function, responsibility and funding of the service, and at the same time allow flexibility. The Primary Health Care Access Program and the Aboriginal Coordinated Care Trials are examples of approaches that have allowed for cashing out and pooling of funds in order to meet specific circumstances.11 Concurrent with this flexibility, local community involvement with planning, development and evaluation of a service is crucial to ensure acceptance and harmonious working relationships and to maximise the use of services.
At the micro level, several specific service requirements must also be fulfilled. These relate to workforce organisation and supply; funding; governance, management and leadership; service linkages, and infrastructure. These factors are closely inter-related and interdependent. For example, recruitment and retention of the health workforce becomes much less of an issue when adequate infrastructure, good management, professional development opportunities, clear role delineation and a supportive critical mass of practitioners are developed.
Effective and sustainable rural and remote PHC models provide consumers with access to appropriate quality care within realistic cost constraints. Our review identified a number of critical policy issues relevant to the provision of sustainable primary health services for small rural and remote communities.
Firstly, the inter-relationship between the essential service requirements of sustainable PHC services highlights the need for a systems approach in which components of sustainability are identified and their inter-relationships measured.8 Focusing solely on individual components (such as workforce supply) without regard to their relationship to, and the importance of, related parts has had limited impact. Sustainable solutions depend on systematically addressing all the requirements outlined in Box 2.
Examples of successful models that meet these requirements can be seen in various multipurpose services, coordinated care trials and shared care models — for example, the Mallee Track Health and Community Service in Victoria, the Katherine West Health Board in the Northern Territory, and the Mental Health Initiative in Tasmania, respectively, and other medical, allied health and palliative care models (such as the Easy Entry, Gracious Exit model in New South Wales, the North West Queensland Allied Health Service and the Griffith Palliative Care Service in NSW, respectively).
While these models emerged in response to different impetuses (such as workforce shortage, unacceptable suicide rates in the region, or the need for comprehensive and coordinated primary care), each recognised that their ongoing viability depended on, and benefited from, meeting all these essential service requirements. For example, overcoming the difficulties of attracting and retaining primary health workers in small isolated communities in the Mallee region of Victoria and in north-western regions of Queensland and NSW was addressed by inspirational leadership and flexible workplace initiatives underpinning the development of innovative service models that provided stimulating and professionally rewarding, team-based working environments. Importantly, these models are able to respond flexibly to the changing health services environment and capitalise on new opportunities.
Secondly, the provision of appropriate, sustainable PHC services in small rural and remote communities requires fitting local solutions within a wider conducive political environment.20 The importance of macro-scale health policies and funding paradigms that underpin the environment of what is possible and what is likely to be supported should not be underestimated. Micro-scale service interventions that are not congruent with macro-scale policies are unlikely to yield sustainable results. Within a rapidly changing health environment, rural and remote health services need to maximise their ability to capitalise on new policy and program opportunities that facilitate local flexibility and make management changes necessary to meet local needs. The importance of developing a harmonious relationship between governments, health services, practitioners and communities that is characterised by effective communication and shared goals is especially vital in developing and maintaining appropriate, sustainable health services in small rural and remote communities.
Health systems worldwide are experiencing a fiscal squeeze resulting from an increased burden of chronic disease due to population ageing, changing consumer expectations, increasing use of technology, and problems of workforce supply. Against this backdrop, providing adequate, good-quality, sustainable health services for many rural and remote communities is particularly problematic in view of their small size, dispersion, and poorer health status compared with larger cities.
Given their diversity, it is clear that a “one coat fits all” model is inappropriate. While a PHC focus on health promotion, illness prevention and early intervention offers the greatest promise of ensuring a long-term improvement in health outcomes, Australians living in non-metropolitan areas still require access to health services that provide diagnosis, treatment and follow-up for existing health problems or for routine check-ups. Whatever the “coat” used to ensure that these health needs are met in a timely and equitable manner, rural and remote health service models will only be sustainable if the service requirements identified by our study of “what works well where” are met in a systematic fashion, and these principles are applied to meet local circumstances.
2 Enablers and requirements of sustainable rural and remote primary health care services
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